Basic Information
| Provider Information | |||||||||
| NPI: | 1205898335 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHAPARRAL MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 TOWNE CENTER DR | ||||||||
| Address2: | ADMINISTRATIVE RESOURCES | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917675900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093981550 | ||||||||
| FaxNumber: | 9093981573 | ||||||||
| Practice Location | |||||||||
| Address1: | 585 NORTH MOUNTAIN AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917868516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099462228 | ||||||||
| FaxNumber: | 9099468007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | ADRIENNE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACTS ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9093981550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | GR005295D | 05 | CA | MEDICAID |